MIGRAINE UPDATE Karen L. Bremer, MD November 16, 2018 Objectives & Disclosures Learn techniques used to diagnose headaches. Become familiar with medications used for headache treatment. Disclosure: I am a paid speaker for Amgen/Novardis. 1
Common Causes of Headache Primary headache Pain for the sake of pain. Migraine Tension Ice-pick (brain freeze) Cluster Secondary headache Pain due to another cause: Infection (flu) Head injury (concussion) Bleeding in the brain or stroke Tumor Headache History Where is your headache (pain) located? Does the pain spread? How and when did it start? What is the pain like? Is it throbbing, stabbing, shooting, pressure, aching? When you have a headache, do you have sensitivity to light or sound? Are you nauseated? Do you have fever or chills? When did you start having headaches? How often do you have headaches? How long do your headaches usually last? What makes your headache better? What have you tried for your headaches? What makes your headaches worse? Movement Light Sound Bending over What triggers your headaches? Weather changes Stress Foods Odors Lack of sleep How severe is your pain, on a scale from 0-10? 2
Headache Examination Head and neck Pupils, fundoscopic exam, eye movements Palpate the area of pain Cranial nerves Carotid auscultation (for bruits) Neurological exam Strength, reflexes, coordination, sensation International Headache Society Classification of Headache Disorders IIIB International Headache Society (IHS) Criteria for primary Headaches Migraine without aura (Common) 5 attacks duration: 4-72 hours At least 2: unilateral, pulsating, moderate or severe, aggravation by activity At least 1: Nausea and/or vomiting Photophobia and phonophobia Symptoms are not suggestive of secondary headache. 3
International Headache Society Classification of Headache Disorders IIIB International Headache Society (IHS) Criteria for primary Headaches Migraine with aura At least 2 attacks One or more fully reversible aura symptom At least 3 of the following: develops gradually over 5 minutes or more 2 or more aura symptoms occur in succession Each individual aura symptom lasts 5-16 minutes At least one aura symptom is unilateral At least one aura symptom is positive The aura is accompanied or followed within 60 minutes by a headache Symptoms are not accounted by another headache disorder. 4
Migraine Aura vs. TIA AURA TIA Positive visual symptoms gradual onset/evolution sequential progression repetitive attacks of identical nature flurry of attacks mid-life duration: 20 minutes headache follows 50% Visual loss abrupt simultaneous duration <15 minutes headache uncommon 5
Migraine Aura International Headache Society Classification of Headache Disorders IIIB IHS Cluster headaches At least 5 attacks severe, unilateral orbital, supraorbital, and/or temporal pain lasting 15-180 minutes. Associated with at least one ipsilateral sign: Conjunctival injection, lacrimation, nasal congestion, rhinorrhea, forehead and facial sweating, meiosis, ptosis, eyelid edema Frequency: 1 every-other-day to 8 per day No suggestion of organic headache. May be precipitated by alcohol 6
Diagnostic testing: neuroimaging and lumbar puncture In patients with recurrent migraine, neither CT nor MRI is warranted except in cases where: recent substantial change in headache pattern history of seizures focal neurological symptoms or signs Lumbar puncture is indicated in the following circumstances: the first unusually severe headache thunderclap headache with negative CT head subacute progressive headache headache associated with fever, confusion, possible meningitis, or seizures high or low spinal pressure suspected (even if papilledema is absent) Treatment options: Acute pain First-line agents Triptans Sumatriptan, Rizatriptan, Almotriptan, Naratriptan, Zolmatriptan, Eletriptan, Frovatriptan Dihydroergotamine (DHE) Combination analgesics (ASA/caffeine/acetaminophen, and others) NSAIDS Naproxen, Ibuprofen 7
Triptans - Serotonin 5HT 1b/1d receptor agonists Indicated for use in migraine headache. Use limited to about 6-9 per month. Expensive (except for generic forms) Indicated for migraine but may have benefit for other headache types Contraindicated in uncontrolled hypertension, heart disease, stroke. Sumatriptan: 25, 50, 100 mg PO, 5&20 mg nasal, and 6 mg SQ Rizatriptan 5, 10 mg PO + MLT. Naratriptan 1, 2.5 mg PO Zolmitriptan 2.5, 5 mg PO + ZMT + Nasal. Eletriptan (Relpax) 20, 40 mg PO Almotriptan (Axert) 6.25,12.5 mg PO Frovatriptan (Frova) 1, 2 mg PO Ergotamines Historically useful in migraine headache. Less selective receptor action. More side-effects (nausea) Same contra-indications as for triptans. DHE-45 (dihydroergotamine) still used (intra-nasal) for migraine. 8
Combination analgesics Many over-the-counter (OTC) and prescription (Rx) preparations available. Effective for mild-moderate migraine. Inexpensive. Tell your doctor if you are taking any of these. Risk of overuse. Recommend limiting use to less than 10 doses per month. If using more than once per week, recommend adding on a preventive. NSAIDs Over-the-counter and Rx available, multiple brands and generics. Ketorolac very effective but usually administered as a shot in the emergency room or clinic. Diclofenac 50 mg powder FDA approved for migraine OTC and Rx (naproxen/ibuprofen) effective for mildmoderate migraine and used in combination with triptans for moderate to severe migraines. 9
Adjunctive agents Anti-nausea medications Promethazine Ondansetron Metoclopramide Anti-cholinergics (promote sleep and decrease side-effects of other medications) Diphenhydramine Benztropine Anti-anxiety medications Diazepam Narcotics (high risk of overuse) avoid Treatment Options: prevention First-line agents Amitriptyline Propranolol Valproic acid Topiramate Verapamil Candesartan Chronic migraine Onobotulinumtoxin A New meds: CGRP antagonists Herbal therapies Magnesium 400 mg BID Riboflavin 400 mg daily (AM) CoEnzyme Q10 (100 TID) Butterbur Feverfew Other: Sphenocath Occipital nerve block Capsaicin nasal spray Cefaly device Gammacore device 10
Preventive agents: ---------------- Decrease frequency/severity of migraine Tricyclic antidepressants Amitriptyline Nortriptyline Aim for 50% reduction (it s no cure). Start with very small dose (10 mg) and increase slowly. Common side-effects are drowsiness, dry mouth. Preventive agents: ------------------ Decrease frequency/severity of migraine heart or blood pressure medications Beta Blockers Use centrally acting agents. Propranolol and atenolol are preferred. Low dose Can make patients light-headed, depressed. Calcium Channel Blockers Verapamil used less than other agents listed here. Angiotensin Receptor Blockers Candesartan found recently to be effective for migraine prevention. 11
Preventive agents: ------------------ Decrease frequency/severity of migraine Anti-seizure medications Valproate Not for use in women who may get pregnant. Can cause weight gain, tremors, hair loss, liver enzyme elevations, decreased platelets. Topiramate Not for use in women who may get pregnant. Can cause weight loss, tingling in the feet and hands, kidney stones. Preventive agents Botox Indicated for treatment of chronic migraine headache (CM). CM = headaches more than 15 days per month lasting >4 hours per day More than 8 of these must be migraine headaches Expensive (@$2000 per treatment). Covered by insurance. Prior-authorization recommended. Benefits: when effective, decreases frequency and/or severity of migraine 50%. Risks: Expensive and may not work Pain at injection sites Ptosis (droopy eye) Nausea Dry mouth 12
Botox injection sites ----------- CGRP antagonists Monoclonal antibodies target and block the CGRP system (calcitonin gene related peptide). Erenumab targets the receptor. F and G target the CGRP molecule. All given by self-administered sub-q doses In order of FDA approval: Erenumab aooe - monthly Fremanezumab vfrm monthly after initial loading dose Galcanezumab gnlm monthly or every 3 months. Letters after generic name refer to the original molecule (biologic) to differentiate from generic products which may come later. Prescribed through specialty or home pharmacy after prior authorization approval. 13
Conclusion: Migraine diagnosis is made clinically. Start keeping a headache diary. There is no test to confirm a diagnosis of migraine headache. Lots of migraine and headache treatments are available. 14